MEMBERSHIP APPLICATION FORM - NBVI - Long Bay
Confidentiality: Any Confidential information requested is for our records and for the funding our organization receives. The answers you provide will be kept completely confidential. Your cooperation providing this information is both appreciated and necessary. Required fields are denoted with an asterisk(*)
Applicant
*
First Name
Last Name
Nickname
Applicant Photo
*
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GENDER
*
Male
Female
Other
Date of Birth
*
-
Month
-
Day
Year
Date
ADDRESS
*
City
State/Province
*
Zip Code
*
School (If Applicable)
PHONE NUMBER
*
Email Address
*
example@example.com
ETHNICITY
*
African
Asian
Bi-Racial
Caucasian
Caribbean
Haitian
Hispanic
Multi-Racial
Pacific Islander
Other
Family Setting
Self
Both Parents
Single Parent
Grandparents
Legal Guardian
Other
Parent/Guardian (If Participant U16):
*
First Name
Last Name
Gender
*
Male
Female
Address
*
City
State
*
Zip Code
*
PHONE NUMBER
*
Email Address
*
example@example.com
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The STA also uses the following fields to learn more about your child. Please one item from each group below
Referring Organization/Outlet
*
Facebook
Instagram
Community Board/Ad
Friend
Parent Referral
Other
Swimming Level:
*
Parent & Toddler
Beginner Swimmer
Intermediate
Advanced
Adult
Programme of Interest:
*
Snorkeling
Advanced
Scuba
Diving
Fishing
Paddling Boarding
Art for Awareness
Surfing
Other
Medical Information
Please enter N/A if information is unavailable, and enter all 0's for phone number if no physician available.
Insurance Company
*
Insurance Policy Number
*
Medications
*
Medical Problems/Allergies
*
Physician:
*
First Name
Last Name
Physicians Phone
*
Disabilities
*
Pickup Information
Person 1:
*
2.) First Name
Last Name
Phone
*
Relationship
*
Acquaintance
Emergency Contact
Primary Emergency Contact
Lives with member
Other
Person 2:
*
2.) First Name
Last Name
Phone
*
Relationship
*
Acquaintance
Emergency Contact
Primary Emergency Contact
Lives with member
Other
Pick Up Authorization Password
*
Facebook
Yes
No
Username/Email Address
example@example.com
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I have read the complete application, understand the rules of the STA and request that my son/daughter be admitted into membership. Although every effort will be made to prevent injury, if an injury should occur to my child while participating in water based activities, I agree to hold STA, its agents and employees, and any volunteers/employees harmless.
CONDUCT Swimmer and Parent will: Agree to abide by the code of conduct. Never argue with or verbally abuse an official. Always use the appropriate rules and guidelines to resolve a dispute. Conduct yourself in a sportsman-like manner and respect fellow swimmers, coaches, managers, staff, officials and the achievement of opponents. Do not bully or take unfair advantage of another competitor. Cooperate with your instructor, coach, and classmates. Refrain from possessing, consuming prohibited substances while in STA programmes or events. Do not consume or purchase alcohol and tobacco while in STA camps/sessions or. Any breach of the Code of Conduct, or any part of it, may result in disciplinary action under the STA, Regulations and policies.
I grant the STA the unlimited right to use and/or reproduce photographs or likenesses in any legal manner for the internal or external promotional and information activities of the STA. I also agree to allow my child to be interviewed and/or photographed by representatives of the external news media in relation to any and all coverage of in which he/she is involved. I also agree to allow my child's work and/or photograph to be published on the STA Web site/Internet pages, and publications. I further understand that by signing this release, I waive any and all present or future compensation rights to the use of the above stated material(s
PLEASE NOTE THAT FEES ARE NOT TRANSFERABLE NOR REFUNDABLE. FEES ARE DUE IN ADVANCED THE OF EACH MONTH
Parent/Guardian Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: